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Inclusion Health Service at St James’s Hospital

In the midst of the homeless crisis in Dublin, one doctor has managed to make a real and positive impact in the health and wellbeing of those living on the streets.

Cliona Ní Cheallaigh

Dr Cliona Ní Cheallaigh, a consultant in general medicine and infectious diseases at St James’s Hospital in Dublin, has just completed a 12-month Inclusion Health pilot project at the hospital. Cliona and nurse Ann Marie Lawlee have successfully reduced the rates of admission, re-admission and length of stay of homeless patients.

The Inclusion Health Service at St James’s Hospital is one of the first of its kind in the world and recognises the complex medical and psychosocial needs and health inequalities experienced by the homeless, asylum seekers, prisoners and Travellers, for example.

“If you look at people who are homeless or other marginalised groups, the amount of trauma they have suffered in their lives is huge. A lot of them, probably up to three-quarters, have had severe sexual or physical abuse in childhood and in a way, more damaging is the neglect,” explained Cliona.

“They haven’t had a parental figure to help them feel safe and loved and regulate their emotions. I would see that that is the route of all the behaviours and difficulties in addiction, difficulties interacting with other people and difficulties in interacting with health services.

Throughout her career, Cliona has demonstrated a personal dedication to helping the marginalised in society and trying to prevent them from falling through any cracks in the health service.

“In my view, the primal human need is to feel loved and accepted and until you have that, you are not going to be able to address taking your hepatitis C treatment or whatever it is. So we really try to provide a service that, within professional boundaries, provides that personal warmth,” she said.

Minister for Health Simon Harris said he was supportive of the work being done by Cliona in St James’s and would like to see the Inclusion Health Service extended to other hospitals.

“In our health service we have many extraordinary doctors, but in Cliona and St James’s we have seen a doctor who has gone above and beyond in terms of coming up with new and innovative ways for caring for some of our most vulnerable patients, often homeless people. I think it is very important that what she is doing is fully supported and supported on a sustainable and long-term basis,” he said.

As part of the pilot project, the Inclusion Health Service was notified whenever a new homeless patient was admitted to the hospital and Cliona or Ann Marie would visit them and take responsibility for their needs. These could range from something basic like pyjamas, to ensuring they had any medication they needed.

“We go and see them. We give them clean pyjamas, make sure their methadone is sorted out, give them a friendly face, say hello, make them feel welcome, it is so simple and it makes such a difference and it doesn’t cost much. All patients should have that. It is just making sure that those who are least likely to get it, definitely get it,” said Cliona.

Studies have shown that homeless people suffer from an increased number of complex medical and psychiatric conditions and are more likely to need acute care. They also have more visits to Emergency Departments, longer inpatient stays and use an estimated 20 times more hospital bed days. Homeless patients also frequently leave hospital without being assessed, leave hospital against medical advice and fail to attend outpatient appointments.

Despite representing just 0.4pc of the catchment population of St James’s, homeless people account for almost 10pc of ED attendances and inpatient stays.

Over the past two years, there have been up to 20 homeless inpatients in St James’s Hospital at any one time, with an average of two homeless patients per month experiencing significantly delayed discharge by up to 12 months.

A lack of suitable step-down accommodation for homeless patients once they are discharged from hospital can also mean that they are more likely to need re-admission.

Cliona worked closely with the staff in Merchant’s Quay Ireland Homeless and Drugs Services, showing the co-operation that can exist between hospital and community services to help patients.

She explained that the traditional hospital approach of admitting a patient with an acute infection, for example for a few days on IV antibiotics and then discharging back again simply doesn’t work for marginalised groups like the homeless. Unless their other complex needs such as addiction or homelessness are met, they are more likely to be readmitted.

One of the biggest and continuing challenges faced by the project has been the lack of appropriate step-down accommodation for homeless patients once they are discharged from hospital.

 “The lack of appropriate accommodation is huge, it ensures worst outcomes for the patient and it also puts a huge burden on the hospital because we don’t have anywhere safe or appropriate to send them. If we do send them out and it is not appropriate, they tend to come back in,” she said.

Despite the difficulties, the service has seen very positive results.

“The number of homeless people has gone up in Dublin but the number of homeless people coming into James’s has gone down. We estimate we have saved about 200 admissions and about 2,000 bed days in the year’s pilot,” said Cliona.